A gender-based review of workplace violence amongst the global health workforce—A scoping review of the literature

Workplace violence (WPV) impacts all levels of the health workforce, including the individual provider, organization, and society. While there is a substantial body of literature on various aspects of WPV against the health workforce, gender-based WPV (GB-WPV) has received less attention. Violence in both the workplace and broader society is rooted in gendered socio-economic, cultural, and institutional factors. Developing a robust understanding of GB-WPV is crucial to explore the differing experiences, responses, and outcomes of GB-WPV with respect to gender. We conducted a scoping review and report on the prevalence and risk factors of GB-WPV in healthcare settings globally. The review followed the Preferred Reporting Items for Systematic and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). We registered the scoping review protocol on the Open Science Framework on January 14, 2022, at https://osf.io/t4pfb/. A systematic search was conducted of empirical literature in five health and social science databases. Of 13667, 226 studies were included in the analysis. Across the studies, more women than men experienced non-physical violence, including verbal abuse, sexual harassment, and bullying. Men experienced more physical violence compared to women. Younger age, less experience, shifting duties, specific clinical settings, lower professional status, organizational hierarchy, and minority status were found to be sensitive to gender, reflecting women’s structural disadvantages in the workplace. Given the high prevalence and impact of GB-WPV on women, we provided recommendations to address systemic issues in clinical practice, academia, policy, and research.


Introduction
To achieve universal health coverage by 2030, the World Health Organization (WHO) and the Global Health Workforce Alliance adopted the global human resources for health (HRH) strategy in 2016.A foundational principle of the strategy is to "uphold the personal, employment, and professional rights of all health workers, including safe and decent working environments and freedom from all kinds of discrimination, coercion, and violence" [1], p.3.However, research demonstrates that workplace violence (WPV) is a significant issue impacting safe work environments for healthcare providers, with far-reaching impacts on individuals, healthcare organizations and society [2].
In 2002, the International Labour Office (ILO), the International Council of Nurses (ICN), the WHO, and Public Services International (PSI) launched a joint program aiming to develop a framework and guidelines for the prevention and elimination of WPV in the healthcare sector [3].The general definition of violence adopted by the framework (2002) is "incidents where staff are abused, threatened or assaulted in circumstances related to their work, including commuting to and from work, involving an explicit or implicit challenge to their safety, well-being or health" [3], p.3.Over time, this definition has been followed by diverse sources [2,4], including healthcare which is operationalized in this review.While definitions for various forms of WPV vary widely in different legal jurisdictions and various academic and research studies, we have considered definitions for this review listed in S1 Appendix.
Since the implementation of the above framework by ILO, ICN, WHO, and PSI [2002] to address WPV in the health sector, several studies have been conducted on various aspects of WPV, including the prevalence, risk factors [4,5], and interventions to de-escalate or eliminate WPV.Studies have been conducted in different clinical settings, geographic locations [6][7][8] and for different populations in the health workforce.Some studies reported the prevalence of WPV in the last 12 months or six months, while others did not specify the time period.Considering the heterogeneity, we included all the studies that reported gender-segregated data for WPV in the health workforce for this review.
Additionally, some studies reported the prevalence of WPV, which is alarmingly high in certain countries and professional groups.For instance, the prevalence of WPV for nurses was 91% in the USA [9] and 72% in China [10].Higher incidences of WPV were also reported for physicians in India (41%) [11], and in Australia (58%) [12], and both nurses and physicians in Barbados, where nurses were twice (OR = 2,95% CI 1-5) as likely as physicians to experience verbal abuse [13].While WPV can affect all healthcare providers, it is particularly problematic for women, who dominate the health workforce in most countries [2].Some studies report differences in prevalence among male versus female healthcare providers [5,14].Our initial impression of the literature is that the issue of gender-based workplace violence (GB-WPV) has received little attention in academic and policy literature, and it is to this aspect that we will now turn.

Influence of gender on workplace violence
Gender-based workplace violence (GB-WPV) is a worldwide issue rooted in a global culture of discrimination driven by socio-economic, cultural, and institutional factors [3].While genderbased violence can affect people of all genders, it predominantly affects women, who experience discrimination at higher rates than men and are subjected to various kinds of violence in multiple contexts, most often carried out by men [15,16].The United Nations Committee on the Elimination of Discrimination against Women (CEDAW) defined gender-based violence as "violence that is directed against a woman because she is a woman or that affects women disproportionately" [17].In 2002 case studies were conducted in seven countries (Brazil, Bulgaria, Lebanon, Portugal, South Africa, Thailand and Australia) as part of the ILO, ICN, WHO, and PSI joint program on workplace violence.The case studies revealed that more than 50% of the participants across all healthcare providers in each country, regardless of their profession and gender, experienced physical or psychological violence [18].In more recent studies, WPV has been reported as particularly harmful to women due to their global preponderance in the health workforce and the impact of gendered power relations that disproportionally impact women [2,15].Therefore, addressing the issue of GB-WPV is critical to meaningfully addressing the issue and supporting the recruitment and retention of women in the health professions [2].
We present a scoping review focused on understanding GB-WPV and related aspects of the global health workforce, including midwives, nurses, and physicians.Our preliminary literature review found that most sources understand gender-based violence as violence against women, including the CEDAW; however, GB-WPV affects everyone regardless of where they identify on the gender spectrum.Since most studies in this global review considered gender as binary (men and women; and a few studies [19][20][21] included non-binary personnel, which was less than 4% of the sample in those studies, in Table 1, they also reported findings for men and women); to report data we defined gender as a binary (male/female) for this review.The specific objectives were: 1. Map the most frequent forms and prevalence of GB-WPV for midwives, nurses, and physicians in different contexts and clinical settings.
2. Identify the gendered dimensions of the health workforce that underpin violence against male or female health workers.
3. Identify gaps in the state of knowledge to recommend empirical research studies.

Protocol registration and study design
We conducted the scoping review according to Joanna Briggs Institute's (JBI) revised guidelines [22].The protocol (S2 Appendix) was registered on the Open Science Framework on January 14, 2022, and can be accessed at https://osf.io/t4pfb/.We utilized the scoping literature review design to address the questions and to cater to the heterogeneous and complex literature because it is an appropriate method to explore the extent of the literature, map and summarize the evidence, and identify and analyze the knowledge gap to inform future research [23].This framework consists of eight steps and originated from the seminal framework of Arksey and O'Malley's scoping review [24], which was advanced by Levac and colleagues [25].In the revised guidelines, JBI aligned the eight steps with the Preferred Reporting Items for Systematic and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) [26], which is used to report the conduct of the scoping review that provided rigour, transparency, and trustworthiness [23].Please see the filled PRISMA-ScR Checklist S3 Appendix.The first step of the scoping review framework is to align research objectives with the title and the inclusion criteria, which we have described in the earlier section and the inclusion criteria (see Box 1).

Search strategy
The research team developed a comprehensive search strategy in consultation with the health sciences librarian.The search focused on the systematic search of published literature in the databases, including Ovid MEDLINE: Epub Ahead of Print, In-Process and Other Non-Indexed Citations; this search was then translated into CINAHL Plus, APA PsycINFO, Web of Science, Gender Studies Database, Applied Social Sciences Index & Abstracts (ASSIA) and Sociological Abstracts (see Ovid MEDLINE search strategy in S4 Appendix).The search terms related to the population (midwifery, nursing, and physicians), concepts (violence and gender-based violence), and the context (healthcare) and appropriate combinations were used for searching for the scoping review [23].These terms were identified from the preliminary literature search on different aspects of WPV using Google Scholar.The final search results were exported to EndNote.After de-duplication, these sources were imported into Covidence, an online program to streamline the screening process by two independent reviewers.To cover multifaceted gender-based WPV comprehensively from global perspectives required significant conceptual development and synthesis.The most recent search of the literature review for this study was conducted on 11 February 2024.

Evidence screening and selection
The identified sources were selected based on the set inclusion criteria in Box 1. Two independent reviewers screened the title and abstracts for shortlisted sources.The discrepancies were resolved with discussion and consensus and by reviewing the complete source, followed by a full-text review for selected sources against the set inclusion criteria by two reviewers and the

Box 1. Study selection criteria
Inclusion Criteria for Studies 1.The study participants included midwives, nurses, and/ or physicians who experienced WPV during their careers.
2. Provided sex-segregated data for any form of violence among midwives, nurses, and physicians, including students, globally.

Data extraction
Data from all included studies were extracted into Microsoft Excel; information was charted regarding author/s and year, title, source, country, objective/purpose, study design and methods of analysis, sample size, and category of health worker and sex/gender-segregated, key findings, and research gaps indicated by the author/s [23].

Data analysis and synthesis of results
Data from articles that reported descriptive statistics regarding sex/gender were included in mapping the prevalence of GB-WPV (Table 1) for several types/forms of WPV and the clinical setting.Some studies treated gender as a risk factor or a predictor for the outcomes of WPV, harassment, and discrimination using inferential statistical analysis presented in Table 2.We  could not calculate a mean score for violence based on gender because of variability in the definition of the terms and the concepts from various contexts (Please see S1 Appendix for definitions of the various forms of WPV).Besides prevalence and gender as a risk factor, other data are described qualitatively, including the risk factors or predictors, the distribution of WPV based on professional category, the professional hierarchy, the perpetrators, reporting systems, and any preventive interventions and their outcomes.Given the overall objective of the review to map the most frequent forms and prevalence of GB-WPV for midwives, nurses, and physicians in different contexts and clinical settings, a quality assessment of the identified sources was not conducted.This paper describes the prevalence of WPV based on gender, the influence of gender and the clinical setting, the professional status/role, and the professional hierarchy and gendered roles and responsibilities that have marginalized either males or females within the professional categories.Other aspects, such as perpetrators of GB-WPV and findings of qualitative studies, will be reported elsewhere.

Description of identified studies
After de-duplication, 9529 possible references were imported for screening in the Covidence.These studies were screened against the title by one person, 1751 were shortlisted to be  We present findings for midwifery, nursing, and medical workforce samples and subsamples only from across the world.Most of the included studies were conducted in the USA (n = 63), followed by China (n = 20), Turkey (n = 9), Australia (n = 9 [2 studies also included New Zealand]), Italy (n = 9), Saudi Arabia (n = 9), Iran (n = 8), The UK (n = 6), Canada (n = 6), Jordan (n = 6), Brazil (n = 5), Greece (n = 5), Pakistan (n = 5), Ethiopia (n = 3), India (n = 3), Norway (n = 3); 11 countries/special regions including Bangladesh, Taiwan, Ghana, Spain, Germany, Kenya, Poland, South Africa, Switzerland, Palestine, and Cyprus had two studies each (n = 22); 29 other studies conducted one in each country and Six used a global sample from other platforms, such as conferences and professional/research forums.

Prevalence of gender-base workplace violence
A total of 226 studies provided sex-segregated descriptive data for WPV.Of the 226, 185 studies [5, 7, 11-14, 19-21, 27-202] provided sex-segregated prevalence data (descriptive) for different forms of WPV (see Table 1).Forty-one studies  provided inferential statistics for violence about gender as a risk factor or predictor of consequences of WPV (Table 2).Of 185 studies that provided descriptive statistics for various forms of WPV, 119 studies (64%) reported a higher prevalence for women participants for all forms of violence as opposed to 31 studies (17%) that reported a higher prevalence for men participants (Fig 3).

Factors affecting workplace violence
Not all studies were aimed at assessing workplace violence based on gender; therefore, we included all studies that either provided data on gender-based workplace violence or findings that indicated gender was a factor for WPV or a predictor for various outcomes of WPV.The latter group of studies had various aims, including: to assess factors associated with workplace violence [19, 27-33, 139, 204-207, 243], to assess the association between aggression, psychological distress, and job satisfaction [34,35,120,187], to determine injuries resulting from physical assaults [203], to determine the relationship between WPV and psychological and behavioral responses [35-37, 161, 200, 202, 208-211], to assess effects of lateral violence and its consequences [38,212], and to assess the preparedness to respond to sexual harassment before and after a workshop [39,65].In addition to gender as the basis for WPV, we classified other factors associated with WPV that were not explicitly gendered, such as age and status (presented below).However, these factors are implicitly aligned with the broader societal norms and the inherent patriarchal structure of the health system, including the health workforce that assigns roles and responsibilities to male and female healthcare providers based on their gender, leading to differential experiences, including exposure to workplace violence, we present in the following section.
The studies also reported on the differential effects of WPV on men and women.For instance, women were significantly more likely than men to experience changes in mental health and social behaviours [89,96,117,130,191,200,208] because of violence.Violence is also reported to have affected female healthcare providers' career goals and development [44,88,118,154,175], leading to dissatisfaction [34,118,175] and burnout [34,45,102,117,121,128,174,209], and leaving or considering leaving the workplace [7,46,80,175,212,217,219,225].However, these consequences were rarely highlighted for men.A recent study compared and found an inverse association between workplace violence and patient safety behaviours among nursing interns in China, in that male nursing interns were more likely to exhibit poor patient care behaviour.In contrast, female nursing interns were more likely to exhibit poor mood [200].In addition to gender, the following demographic factors were related to the risk of WPV among healthcare providers.
Work experience.Several studies reported on an association between the years of experience and the occurrence of different forms of WPV, and most studies found this relationship to be inversely proportional [12,35,49,76,98,99,111,123,124,146,152,171,194,203,204,212,214,219,223,[227][228][229].We analyzed the forms of violence which had a higher prevalence for either men or women to examine any connection to years of work experience.Studies reported that men experiencing more verbal abuse [219], physical violence [123,146,171], and bullying [218] had the least work experience.Similarly, less experience as a factor for verbal abuse [98], sexual harassment [12,149,152], physical violence [124], horizontal violence [229], bullying [35] and aggression [159], in studies which reported women as victims of WPV.In addition, the increased experience seemed to be a protective factor against physical violence among nurses [228].
In a Greek study, the prevalence of bullying was higher among women (nurses and physicians); however, women physicians self-labelled as being victims more often than nurses [87].Another study in India reported that physician participants experienced more episodes of WPV (77%) followed by nurses (48%); the overall prevalence rates were higher for women [14].In the context of Saudi Arabia, in a study, both physicians and nurses (68.5% vs 68%) [73], and in another study, nurses (82%) and medical residents (15%) experienced bullying from various sources [35]; both these studies found overall higher prevalence for women than men (66% vs.49%) [73], (69% vs. 31) [35], that explain gender intersection with professional hierarchy that victimized women.
The formal organizational hierarchy played a role in perpetuating workplace violence due to the inherent power dynamics in the health workforce.One study in Cyprus [165] reported that mobbing, which involves hostile and unethical communication directed systematically towards an individual, was prevalent among women in the workforce, with nurses significantly more affected than physicians.The same study also reported that chief and senior nurses were significantly less exposed to bullying behaviours than junior nurses (33.3% and 46.7% vs. 56.1%).Similarly, a study in a forensic hospital in California, USA, reported men experiencing a higher frequency of assaults in wards than men in clinics and supervisory positions [230].Banga and colleagues [175] included participants from 79 countries who reported that 16% of the participants experienced aggression from their supervisors.In the study, nurses were more likely to experience higher levels of violence than physicians.Fifty-five percent of victims reported job dissatisfaction, and 25% were willing to quit.
Several studies reported exclusively on nursing personnel.A study conducted in Poland reported seniority as a protective factor against bullying and that nurse managers experienced a significantly lower level of bullying compared with clinical nurses and nurse coordinators [226].In China, male nurses who had lower professional titles in intensive care units had higher odds of experiencing WPV [210].Another study from Lebanon reported male nurses' higher risk for exposure to violence, and managers/supervisors were found to be the most common perpetrators of verbal abuse [219].In this Lebanese study, male nursing students reported experiencing discrimination in the female-dominated profession.
Interestingly male medical professionals likewise reported violence and discrimination based on gender.In fact, several studies reported a significant relationship between the role, seniority, and the experience of violence among medical personnel.For instance, male medical residents and General Practitioners (GPs) had higher odds of violence than specialists in an emergency department in Turkey [76], GPs in China [204], and junior residents in India [146].On the other hand, female medical personnel experienced more harassment and discrimination throughout their career, including in academia, regardless of role or seniority.Of 185 descriptive studies, 46 (25%) reported that women in medicine experienced sexual harassment, with trainees and residents most affected [20, 21, 37, 39, 52-54, 74, 75, 78-82, 85, 88, 94, 95, 107-109, 116-119, 121, 126, 127, 130-132, 148, 150, 152, 154, 158, 160, 161, 173, 174, 182, 184, 186, 187, 196].On the other hand, both male (70%) and female (69%) residents in obstetrics and gynecology (OBGYN) experienced sexual harassment in the USA [66].Another study [116] in a US medical college reported that one-third of respondents experienced sexual harassment, a finding that was inversely proportionate to the academic rank held: medical students (51.7%), residents/fellows (31%) and faculty members (25%).Similarly, sexual harassment was higher among women in vascular surgery who did not hold leadership or academic titles and were ranked lower than assistant professors [152].This phenomenon holds true for multiple specialty areas in medicine: respondents from a study in Australia and New Zealand reported a higher proportion of sexual harassment, bullying, and discrimination among female trainees in ophthalmology compared to staff ophthalmologists [132].An online survey of cardiothoracic surgeons also found higher rates of sexual harassment among trainees [85].A recent study [184] reports for participants from 28 countries on Bullying, Undermining, and Harassment (BUH) in peripheral vascular disease department, where women's experience of BUH was higher than men (53% vs. 38%).Medical students reported the highest prevalence of BUH (57%) followed by residents (65.7%), fellows (41%), and consultants (37%).Another study in France included midwifery, nursing and medical student reported higher prevalence of GBV for female student (93.7vs.5.4%).In Canada, a higher proportion of women than men in family medicine experienced intimidation, harassment, or discrimination based on gender, and hierarchy was also identified as a factor [95].Similarly, in orthopedics, women experienced gender-based harassment and sexual harassment significantly higher than men.Similarly, in orthopedics, women experienced gender-based harassment (98% vs.68%) and sexual harassment (83% vs. 71%) significantly higher than men.In this specific study men represented 72% of the sample [19].One US study with a large, representative sample (n = 6000) from a national survey reported that greater women's representation within a specialty is associated with lower sexual harassment for both men and women from coworkers and patients [206].
Clinical routines.Workplace routines for all health workers were found to be risk factors for exposure to violence, including longer working hours [5,151,156,161,171,226], shifting duties, particularly night shifts [14,30,55,56,69,76,124,139,141,155,156,167,172,175,188,219,243], and direct patient care [153,159,172].Night shifts were found to be a risk factor for WPV among male nurses in Bangladesh [30], Iran [69], Lebanon [219], Turkey [76], Korea [139], and China [155,167,243].In Saudi Arabia, male nurses working with more than ten staff members were found to be at risk of verbal abuse [72].Additionally, hours of work and type of position were found to be risk factors for WPV in several studies for women.Working full-time [153], shifting duties [124], overtime/more hours of work [226], and direct patient care [153,159,172] were all associated with higher rates of exposure to violence among female nurses.In the case of medical personnel, male GPs in Australia who worked full-time experienced higher levels of verbal abuse than part-time GPs [12].
Clinical setting.Several studies examined specific clinical settings and the risk for physical and non-physical violent incidences.Most incidents occurred in the emergency department (ED) and psychiatric settings [72, 76, 89, 105, 110, 111, 138, 153, 166, 169-172, 178, 181, 188, 202, 203, 221, 232, 243].Several studies reported female nurses suffering non-physical violence in EDs in China [89,208] and Ethiopia [111] and in psychiatric units in the USA [153]; physical violence was experienced in pediatric clinics in Turkey [138] and China [208], psychiatric units in USA [203], and in the primary/secondary care facilities in Brazil [151].Female nurses also experienced both physical and non-physical violence in ED [232] and ICU [214] in Greece, in adult health in Scotland [57] and in psychiatric units in Japan [110] ED in Iran [188], and South Africa [178].Another study reported female nurses experiencing bullying in the operating rooms and maternity wards [43], and male nurses were reported to experience bullying in medical/surgical units, outpatient clinics, and critical care units [101].Female physicians also experienced bullying and discrimination in laboratory-based specialties and surgical and medical settings [93].Male nurses in Jordan [169] and Saudi Arabia [72] experienced verbal violence in EDs, as did male physicians in Turkey [76].These studies demonstrate that WPV is persistently more prevalent among women and nurses across clinical settings.
Furthermore, several studies reported that more female medical personnel report sexual or gender harassment in male-dominated surgical specialties than in other settings [21,78,85,130,182].In the surgical specialties, the prevalence was higher for women compared to men in cardiothoracic surgery [85,130], pediatric surgery (80%) and neurosurgery [130], and vascular surgery [21].Similarly, sexual harassment was also experienced by female nurses in public hospitals in China [155], Rwanda [7], Ghana [80], and Japan [110].In addition, both male and female nursing students in Taiwan [86] and Catalonia [179] experienced sexual violence during university education.
Ethnicity/nationality.The nationality or ethnicity of the healthcare professionals also was a factor in the experiences of WPV among nurses and physicians.For instance, male nursing personnel in Iran with non-Farsi ethnicity experienced significantly higher levels of physical violence (OR-2.34)[115].Similarly, physical violence was significantly associated with non-Omani and non-Saudi nationality in Oman [71] and Saudi Arabia [171], respectively.In Saudi Arabia, workplace bullying was also more prevalent among expatriate non-Saudi health practitioners [35,73].International Medical Graduates (IMG) in Australia, particularly general practitioners and registrars, experienced significantly higher aggression from patients compared to non-IMGs (63% vs. 52%), from relatives (15% vs. 12%) and coworkers (5.7% vs. 3.9%), and this was highest among female IMG staff [114].In a large academic medical centre in the USA, white female physicians experienced fewer mistreatment episodes than black physicians and those of other races [37].Further, in radiology, women graduates from foreign medical schools were more likely to report sexual harassment compared to the US graduates (77.1% vs. 54.1%)[82].Similarly, in China, non-Asian individuals were more likely to experience harassment, and women reported being offered career advancement in exchange for sexual acts [88].Additionally, bullying was more common among Asians (female faculty members) in a faculty of health sciences in South Africa [58].Bullying and harassment among non-white vascular physicians were reported in 28 countries [184].
Discrimination based on gender experienced by women, where nationality was a factor, was frequently reported by surgical residents in Australia and New Zealand [94] and the USA [107], and in pediatrics (USA) [121].While in Canada, there was no significant difference in the proportion of Canadians (46%) and IGMs (41%) in family medicine experiencing intimidation, harassment, and discrimination (IHD).However, more IMGs perceived IHD based on ethnicity, culture, or language [95].Similarly, surgical residents (8.8%) in Spain experienced discrimination due to their country of origin, including both women and men [128].The data revealed an association between WPV and the minority status globally, except for one instance in a public hospital ED in Saudi Arabia, where more Saudis (51.8%) than non-Saudis (33.8%) experienced incidences of all forms of violence [112].

Discussion
In our comprehensive review of descriptive studies, an apparent gender disparity in the prevalence of workplace violence (WPV) emerged.Overall, 64% of descriptive studies reported a higher prevalence of all forms of WPV for women, including sexual violence, verbal abuse, discrimination, bullying and physical violence.On the other hand, only 17% of the descriptive studies reported men's higher experience in all forms of WPV, including physical violence, verbal violence, bullying and sexual violence.The remaining 19% of the studies that reported higher prevalence for various forms of WPV, either for men or women, are presented in Table 1.All these studies also reported several factors explaining the disparities in prevalence rates for different forms of violence among diverse groups.Firstly, some studies in our review reported insufficient data due to underreporting because of the retrospective nature of reporting mechanisms [83,156,166,203,232], as most of the incidents were reported after they had occurred, thus introducing the potential for recall bias.Retrospective reporting can also affect the participant's ability to accurately recall the incident because, over time, they may tend to express feelings to friends and family members, which helps alleviate distress.Additionally, the reporting hierarchy in the organization and the research process [83,136,232] bring challenges to accurate reporting because of the fear of retaliation by the supervisors, as many were perpetrators of violence [74,233,237].
While these factors contributed to variability in data, they also provided insight for addressing gender-based workplace violence and achieving justice for affected individuals, particularly women, which involves multifaceted dimensions.First, it necessitates shielding individuals from existing and potential aggressors by bolstering policies and reporting efforts to safeguard rights in the workplace, such as fostering a comprehensive understanding of safety within the work environment.Secondly, addressing victims' grievances requires strengthening institutional responses tailored to GB-WPV.Lastly, imposing stringent expectations and repercussions on perpetrators entails heightening the consequences for individuals perpetrating such acts and increasing awareness.This emphasizes three critical approaches: enhancing policies, fortifying institutional capacities, and implementing tailored intervention programs for those involved with GB-WPV [244].In addition, research efforts should focus on understanding barriers to reporting and devising strategies to enhance reporting accuracy, working in tandem with healthcare institutions and supervisors to develop more effective reporting systems and policies that prioritize the well-being and safety of all staff in a way which protects victims of vertical violence.Further, institutions may consider using non-institutional groups to collect and manage information about GB-WPV.Using non-institutional mechanisms may reduce interference by institutional self-interests and reduce gender biases within healthcare [245].
Further, studies in this review reported methodological constraints, including sampling frames (small size, convenience sampling, self-selection, non-representative sample, etc.) [13,81,82,90,106,163,230,234], which may lead to findings biased toward one group or the other.Furthermore, different assessment methods and measurement tools [87,92,122,125,166,223,228,235] have been acknowledged to limit the generalizability of results.Additionally, differential operational definitions of terms [82,95,101,104] and their understanding can limit the reporting and lead to insufficient data.Though we did not critically appraise these studies, or include 'grey literature' sources, we acknowledge that these limitations also limited us to producing a cumulative prevalence in this review.Considering the limitations, we presented the proportions of studies that reported a higher prevalence of WPV for men and women and synthesized factors affecting the disproportionate perveances.
As this is a global study, some regions with limited research capacity are at risk of being omitted from this study.In such contexts, formal studies meeting scientific journal standards may not be feasible, leaving significant gaps in our understanding of GB-WPV prevalence and its impact.One of the studies included in this review sent a worldwide invitation for participation in the study about violence in the health system.Though the study received responses from 110 countries, the researchers excluded responses from 31 countries because of inappropriate responses that did not meet the rigor of the research process [175].In those contexts, incidents of GB-WPV may be documented in various sources beyond traditional scientific literature, such as internal hospital documents and social media, if documented at all.The reliance on "grey data" introduces its own set of challenges, including issues of reliability, consistency, and accessibility, which this review did not undertake.
A recent systematic review of 253 studies could not determine any significant differences in the prevalence of any form of WPV according to sex, which was attributed to the sample of studies; only 27% of studies included in that review presented the sex-segregated findings [4].In our scoping review, we report findings from 226 studies that provided sex-segregated data; WPV is a multifaceted topic where women's experience of violence was disproportionately high for almost all forms and contexts.Developing gender-sensitive programs, processes, and policies in healthcare settings is crucial, including a gender-balanced workforce that could benefit both men and women [206].This approach not only aims to safeguard those from prevalent forms of violence but also acknowledges and addresses the often-understated experiences of violence encountered by men.Training and education sessions have been deemed effective when there is a multidisciplinary approach; they focus on education to enhance knowledge and alter attitudes [244].These tailored initiatives could help mitigate instances of violence [245].In addition, the identified gender-based workplace violence (GB-WPV) trends among healthcare professionals should be investigated using rigorous scientific standards to better explore the phenomenon of GB-WPV and related factors [136].Furthermore, studies must investigate GB-WPV in various clinical settings on a larger scale, including trialing interventions (policies and reporting mechanisms) and their impact by adopting longitudinal, prospective study designs [246].The revised policies and interventions must consider gender mainstreaming (integrating gendered perspectives in all phases and including both men and women in developing programs and policies) before being implemented in the clinical settings.
Gendered power relations within organizational and professional hierarchies played a critical role in enabling WPV between and within professional groups.For instance, studies that included medical and nursing personnel [13] found that gender is a significant predictor (OR = 9) for WPV in primary care clinics.Female nurses and physicians were 11 times more likely to experience verbal abuse and nine times more likely to experience any form of violence than males.This study also reported that nurses have double the risk of experiencing verbal abuse compared to physicians [13].The prevalence of gender-based discrimination was also higher for women within the medical profession in most high income countries, including Australia, the USA, and Canada [74,75,81,95,104,119], as well as Saudi Arabia and India [79,108].These hierarchical gendered relations between men and women reflect those in society at large, and in most cultures and geographic locations, men hold most positions of authority.Preventative measures must be enacted, including robust policies against retaliation and comprehensive training for supervisors on appropriate behaviour.Reforms must consider and confront broader societal gender-based roles of men and women, often reinforcing power imbalances.Recognizing and challenging societal norms is essential to creating sustainable safeguards within healthcare settings, ensuring a more equitable distribution of power and opportunities for men and women.This could include support programs for those impacted.Interventions which expand access to social support are helpful when addressing issues of abuse [247].By integrating gender-sensitive approaches and survivor considerations into these reforms, institutions can strive towards fostering a workplace culture that addresses workplace violence and promotes gender equality and inclusivity.
Historically, men have dominated decision-making, leadership roles, and participation in healthcare organizations as a direct result of patriarchal social structures [248].Male professional domination could explain the higher prevalence of WPV among women in our review in various contexts.In that, men dominated healthcare organizations, specifically medicine, and they also held more institutional power than nurses [248,249].Grant et al. [249] explained that women's voices often face suppression within these arenas, influenced by the attitudes prevailing among those in positions of power and the prevalent culture of blaming victims [249].Similarly, Salles et al. [248] elucidated that the scarcity of women in leadership positions within academic medicine reflects deeply ingrained biases, which are then reinforced by biases favouring men as inherently better leaders.This likely contributes to the disproportionate underrepresentation of women in healthcare leadership roles and less power.Based on the findings on risk factors, there is also a need to understand the interconnected nature of social categorizations and how they intersect with gender to shape the experiences of the health workforce in different situations.
Moreover, WPV involves individuals, groups, and the organization/community.Thus, there is a critical need for policies and interventions to address WPV to target eliminating gender inequality more broadly and to focus interventions at different levels [250].At the level of the individual, interventions should create awareness about the forms of violence, existing policies and mechanisms for reporting that empower individuals to advocate for themselves [251] and others affected by the incidents [127,128,161].We also recommend improving the structural factors, including physical conditions of work and equitable allocation of women and men in positions of authority in the workplace.
Intervention at the organizational level must target changing the organizational climate, focusing on developing and disseminating zero-tolerance policies [250] comprising transparent and trustworthy reporting mechanisms (regardless of the perpetrator, including patients or family members, supervisor, etc.).Proposed interventions include alert systems [166] and 'hot-lines' [211].These mechanisms must be paired with clear and consistent action [132] to handle complaints for investigations that follow through with sanctions and penalties to the offender [85,250].
Moreover, given that gender intersects with other social determinants, strategies must consider these and how they may intersect.For example, the age and professional experience of the victim, the clinical setting, the patients' complexity, the nature of work, and the location of an individual in the organizational hierarchy [113] need deliberate attention for inclusivity.The findings of studies included in this review also call for transformational interventions.For instance, in most cultures, women carry a disproportionate amount of domestic responsibility compared to men and thus may require support to manage their large home and work responsibilities.Flexibility in scheduling and supportive workplace cultures are key to changing the work culture at healthcare institutions.Awareness of the vulnerabilities and pressures on early career professionals who may experience additional pressures, including a higher risk of violence in the workplace and domestic/family pressures at home, is vital to building a sustainable health workforce.Besides, collaborative efforts must be made to alter the cultural and patriarchal systems that contribute to women's exposure to GB-WPV by creating awareness and condemning GB-WPV through media and strategic advocacy directed at appropriate political, cultural, and religious leaders [252].Finally, the programs and policies initiated to respond to GB-WPV should be tested empirically for their effectiveness [217], and interventions that are based on evidence must inform policies and procedures [12,83].
Sexual harassment is a form of violence that has significantly affected women in the health workforce and is enabled by the professional and organizational hierarchies rooted in organizational cultures that provide impunity to perpetrators [253].In our review, 25% of studies reported harassment significantly affected women in the medical workforce, particularly the trainee medical residents in most contexts [20, 21, 37, 39, 52-54, 74, 75, 78-82, 85, 88, 94, 95, 107-109, 116-119, 121, 126, 127, 130-132, 148, 150, 152, 154, 158, 160, 161].Women in nursing also experienced sexual harassment [36,40,49,86,99,129]. On the other hand, lateral violence or bullying was a significant issue highlighted in nursing and midwifery professions [36,212,229].Considering the hierarchical levels that exist within professions and between professions, interventions must be directed to bring change at each level, including at individual (creating awareness and offering protection), organization (transparent and anonymous system for voicing change, flattened hierarchy and leadership training), and at the system level to prevent accumulation of power at the top.Open, transparent reporting relationships, diversity in career pathways and women's inclusion at all levels of leadership have also been suggested as ways to address organizational hierarchy that may perpetuate GB-WPV [254].In addition, mandatory training in programs tailored to recognize, manage, and prevent GB-WPV for all healthcare professionals is imperative [251].Similarly, policy formulation and implementation for preventing and managing WPV at the national level (e.g., Ministry of Health and professional councils and associations) [218,252] and creating reforms for independent monitoring, reporting, and sanctioning to end impunity [250] are crucial steps.To address this issue, governments, irrespective of geographical location, ought to bolster the legal system's capacity to handle cases of sexual abuse effectively including revising labour laws, introducing special legislation and enforcing the same [3].Since the guidelines developed in 2002 by ILO, ICN, WHO, and PSI are useful in addressing workplace violence and guiding governments, we suggest the revision and joint efforts of the global health alliances to revise the "Framework Guidelines for Addressing Workplace Violence in the Health Sector" [3] with regards to strengthening legal systems in all counties.A recent analysis of Canadian court cases of violence against nurses revealed that despite having significant injuries, historically, being a nurse was not always considered an aggravating factor in sentencing under criminal law.Therefore, the authors highlighted the need for ongoing legal efforts to combat the widespread acceptance of workplace violence in healthcare and the enactment or stringent enforcement of laws to safeguard victims' rights [255], thereby providing a more robust framework for protection and recourse against WPV.

Conclusion
Entrenched hierarchical structures often reflect traditional gender norms, where men predominantly hold leadership positions and women are confined to frontline care roles.Simplifying even patient-initiated GB-WPV as a by-product of physical proximity overlooks the deeper systemic issues.Our research reveals how GB-WPV is symptomatic of broader societal injustices rooted in sexism and discrimination, affecting marginalized groups, including women across the globe.These power imbalances create environments where women's voices are marginalized, their concerns dismissed, and their experiences of violence trivialized.This marginalization not only limits their agency but also exacerbates their vulnerability to GB-WPV.Failing to acknowledge the gendered origins of WPV places countless women in healthcare at risk of experiencing clear violations to personhood and enduring adverse health outcomes and premature career disruptions.The repercussions of GB-WPV resonate throughout the healthcare system, resulting in substantial provider attrition, compromised patient care, and an overburdened healthcare infrastructure struggling to meet the needs of society.We acknowledge that looking at a single analytical category, such as gender, negates the complex ways in which other social categories influence experiences of WPV.Further evaluation is needed to understand the interconnected nature of social categories such as race, gender, sexual orientation, socioeconomic status, ethnicity, immigration status, and more, as well as how they intersect to shape the experiences of WPV.

3 . 4 .
Published in English and after 2010.Exclusion criteria Studies that did not provide sex-segregated data 5. Exclude qualitative studies, systematic/ scoping reviews, concept or theoretical papers, and theses.abstraction of the information independently.The selection process is presented in the PRISMA diagram (Fig 1).

Fig 2
Fig 2 presents the proportion of studies(226) included in this paper that used a sample of nurses, physicians and/or the entire workforce.We present findings for midwifery, nursing, and medical workforce samples and subsamples only from across the world.Most of the included studies were conducted in the USA (n = 63), followed by China (n = 20), Turkey (n = 9), Australia (n = 9 [2 studies also included New Zealand]), Italy (n = 9), Saudi Arabia (n = 9), Iran (n = 8), The UK (n = 6), Canada (n = 6), Jordan (n = 6), Brazil (n = 5), Greece (n = 5), Pakistan (n = 5), Ethiopia (n = 3), India (n = 3), Norway (n = 3); 11 countries/special regions including Bangladesh, Taiwan, Ghana, Spain, Germany, Kenya, Poland, South Africa, Switzerland, Palestine, and Cyprus had two studies each (n = 22); 29 other studies conducted one in each country and Six used a global sample from other platforms, such as conferences and professional/research forums.